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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419458
Report Date: 04/26/2022
Date Signed: 04/26/2022 01:04:58 PM

Document Has Been Signed on 04/26/2022 01:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:VOLUNTEERS OF AMERICA,WILEY CANYON HEAD STARTFACILITY NUMBER:
197419458
ADMINISTRATOR:ROCIO GOMEZFACILITY TYPE:
850
ADDRESS:24240 LA GLORITA CIRCLETELEPHONE:
(818) 897-4124
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY: 51TOTAL ENROLLED CHILDREN: 51CENSUS: 41DATE:
04/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Prisma Rubio, Site SupervisorTIME COMPLETED:
01:20 PM
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On April 26, 2022, Licensing Program Analyst (LPA) Monique Ayala conducted a Case Management inspection for the purpose of following up on an incident that was filed with our department on 04/20/2022; the incident was reported timely. Upon arrival LPA met with site supervisor who guided LPA on a tour of the facility. LPA observed 41 children in care with 7 staff.

Description of incident: On 04/20/2022 at approximately 10:50AM, child 1 ran towards the gate of the playground and pushed the gate to open and exit the playground. The gate bounced back and cut C1 in the middle of his upper forehead.

During this inspection LPA interviewed a child, staff, reviewed children files, obtained photos of the playground and obtained a copy of the facility roster.

The information obtained during the interviews revealed that the S1 was in close proximity to C1 during the time of the incident. S1 was approximately 1 foot away from C1. C1 pushed the gate and the gate bounced back and hit C1 on the upper forehead that caused and an injury requiring 2 stiches. S1 was in close proximity and was not able to prevent the incident from happening as the incident occurred fast.

No violation of Title 22 Regulations occurred due to the incident being an accident. No deficiencies cited during this inspection.

An exit interview was conducted and a copy of this report was provided to site supervisor along with Notice of site visit.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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